Resilience amongst Ontario registered practical nurses in long‐term care homes during COVID‐19: A grounded theory study

Abstract Aims This study aimed to understand how the personal and professional resilience of Registered Practical Nurses working in long‐term care (LTC) homes in Ontario were impacted during the Coronavirus 2019 pandemic. Background Registered Practical Nurses are primary regulated healthcare providers that have worked in Ontario LTC homes during the COVID‐19 pandemic. As frontline workers, they have experienced increased stress secondary to lockdowns, changing Ministry of Health recommendations, social isolation and limited resources. LTC homes experienced almost a third of all COVID‐19‐related deaths in Ontario. Understanding registered practical nurses' (RPNs) resilience in this context is vital in developing the programs and supports necessary to help nurses become and stay resilient in LTC and across a range of settings. Methods Purposive sampling was used to recruit 40 Registered Practical Nurses working in LTC homes across Ontario for interviews. Charmaz's Grounded theory guided in‐depth one‐on‐one interviews and analyses completed between April to September 2021. Results Registered Practical Nurse participants represented 15 (37.5%) private, and 25 (62.5%) public LTC homes across Ontario Local Health Integration Networks. Findings informed two distinct perspectives on resilience, one where nurses were able to maintain resilience and another where they were not. Sustaining and fraying resilience, presented as bimodal processes, was observed in four themes: ‘Dynamic Role of the Nurse’, ‘Preserving Self’, ‘Banding Together’ and ‘Sense of Leadership Support’. Conclusion Resilience was largely drawn from themselves as individuals. Resources to support self‐care and work‐life balance are needed. Additionally, workplace supports to build capacity for team‐based care practices, collegial support in problem‐solving and opportunities for ‘connecting’ with LTC nursing colleagues would be beneficial. Our findings suggest a role for professional development resources in the workplace that could help rebuild this workforce and support RPNs in providing quality care for older adults living in LTC. Patient or Public Contribution Our research team included two members of the Registered Practical Nurses Association of Ontario, and these team members contributed to the discussion and design of the study methodology, recruitment, analysis and interpretation. Further, RPNs working in long‐term care during the COVID‐19 pandemic were the participants in this study and, therefore, contributed to the data. They did not contribute to data analysis or interpretation.


| INTRODUC TI ON
Registered practical nurses (RPNs), the largest regulated health professional workforce in Ontario long-term care (LTC) homes, have been at the frontline of the Coronavirus Disease 2019  pandemic (Odom-Forren, 2020). The workforce of the LTC sector has been significantly impacted by the ongoing COVID-19 pandemic, with 79% of all COVID-19-related deaths in Canada occurring in LTC homes (Rothan & Byrareddy, 2020). Only 54% of healthcare providers working in LTC have agreed that following provincial  recommendations (e.g. use of personal protective equipment [PPE], physical distancing of 6 m) was a feasible strategy for managing the pandemic (Siu et al., 2020), highlighting a lack of preparedness in the processes of the LTC sector in the face of crisis. Further, this sector experienced challenges even before the pandemic, such as chronic staffing shortages, low staffing levels, heavy workloads, punitive measures for staff experiencing illness, environmental deficiencies, lack of infection control processes and high levels of selfreported staff burnout (McGilton et al., 2020;White et al., 2021).
Researchers outside of Ontario have also suggested that interventions to improve LTC staff resilience are critical to revitalizing this workforce (Williams, Hadjistavropoulos, et al., 2016;Williams, Lum, et al., 2016). The aim of this study was to understand how the personal and professional resilience of RPNs working in LTC homes in Ontario were impacted during the coronavirus disease-2019 (COVID-19) pandemic.

| Background
The workforce in Ontario LTC homes has been particularly vulnerable to COVID-19. In 2020 in Canada, the largest proportion of deaths from COVID-19 occurred in Ontario LTC homes (i.e. 79%; Rothan & Byrareddy, 2020). From the onset of COVID-19 and throughout 2020 in Canada, Ontario LTC homes were epicentres in the fight against infection transmission. The statistics fail to capture the disturbing social, emotional, psychological and physical impacts the pandemic had on healthcare workers, residents and families. Going forward, it will be important to understand how RPNs experienced a crisis like COVID-19 to make changes necessary to support individual, organizational, policy and social factors that have shaped their experiences. In Ontario LTC homes, a variety of nurses work, including RPNs and registered nurses; however, RPNs have been at the contributed to the discussion and design of the study methodology, recruitment, analysis and interpretation. Further, RPNs working in long-term care during the COVID-19 pandemic were the participants in this study and, therefore, contributed to the data.
They did not contribute to data analysis or interpretation.

K E Y W O R D S
adult nursing, grounded theory, long-term care, practice development, qualitative approaches Impact What problem did the study address?
• Resilience-based educational strategies are used for developing skills in nurses to respond positively to adversity.
• Throughout the COVID-19 pandemic, RPNs working in Ontario long-term care (LTC) homes experienced prolonged lockdowns, challenging working conditions and inadequate resource allocations that have compounded the strain on this historically neglected healthcare workforce.
• Previous research findings from an integrative review of resilience in nurses concluded that understanding resilience can assist in providing support and developing programs to help nurses become and stay resilient.

What were the main findings?
• This is the first study exploring the nature of individual resilience through the voices of RPNs working in Ontario's LTC sector during the COVID-19 pandemic.
• Fueling or draining individual resilience, presented as bimodal processes, were discovered in four themes: 'Sense of Leadership Support', 'Banding Together', 'Dynamic Role of the Nurse' and 'Preserving Self'.
Where and on whom will the research have an impact?
• The insights into the nature of individual resilience from nurses themselves may inform nurses and employer organizations to support and retain novice and expert nurses in the LTC sector.
• The findings suggest there is a role for professional development and workplace solutions for supporting the recruitment and retention of the workforce so they can care for people living in LTC.
• Resilience is important for the retention and recruitment of nurses in LTC homes and future studies need to examine this construct in relation to objectively measured staff and resident outcomes. forefront of the COVID-19 pandemic as the largest regulated health professional workforce in Ontario LTC homes (Odom-Forren, 2020) and are therefore the focus of this study.
In 2019, the Ontario Health Coalition reported a failure to plan and resource the LTC system, despite the predictability of aged population health trends, including the increasing prevalence of dementia and greater complexity of chronic healthcare needs. Currently, as evidence of and response to, the historically underfunded staffing of LTC facilities and the lack of updates in the infrastructure of these facilities, two new national standards for LTC are in development:   resulting from little time for humanistic nurse-resident relationships and a failure to maintain the emotional and psychological needs of residents and nurses (Williams, Hadjistavropoulos, et al., 2016;Williams, Lum, et al., 2016). In Japan, researchers have found that 10% of healthcare workers (i.e. doctors, nurses, other interdisciplinary staff and office workers) developed moderate-to-severe anxiety disorders, and roughly 28% developed depression during COVID-19 (Awano et al., 2020).
The construct of resilience has been identified by the Registered Practical Nurses Association of Ontario (WeRPN) as being central to nurses. Informed by Ungar's (2018) ecological model of resiliency, this construct is understood 'as a sequence of systemic interdependent interactions through which actors (whether persons, organisms, or ecosystems) secure the resources required for sustainability in stressed environments' (Ungar, 2018, p. 33). In this study, resilience in RPNs is viewed holistically, as integrating personal, professional and organizational 'recovery responses' to challenging experiences. Recovery responses may include but are not limited to, self-care activities, targeted education, timely communication from leadership, acknowledgement of demands on workers, opportunities for open discussion and reflection with colleagues and professional development. Ungar (2018) outlines personal resilience as a process by which people 'bounce back' from adversity, frustration and misfortune using the psychological and biological strengths humans employ to cope with challenges and threats (Ungar, 2018).
Professional resilience addresses the capacity of individuals to thrive in demanding workplace situations, exemplified by a willingness to act in responding to difficult situations (Ungar, 2018).
Previous research, addressing how the conceptualization of resilience in nursing influences interventions aimed at increasing resilience, reported that resilience-based educational strategies are used for developing skills in nurses to respond positively to adversity (Stacey & Cook, 2019). However, understanding the nature of resilience in RPNs working in the LTC sector, beyond experiencing the death of residents, is lacking. Rochat et al. (2017) identified risk and protective factors influencing career resilience: the negative effects of limited resources (e.g. material, human capital, social support), and alternatively, strong social support and breadth of skills (i.e. protective factors). Recently, Hite and McDonald (2020) have suggested that both individual and contextual factors influence nursing career resilience. Ungar (2018) suggests that even when a person's individual adaptive resilience processes are present, social and physical ecologies or environmental antecedents, are major players influencing positive outcomes when individuals and organizations are under stress. Conceptualizing resilience in RPNs holistically draws together individual, professional and organizational factors to inform a broad view of the process of how RPNs working in LTC homes in Ontario build and sustain personal and professional resiliency during a crisis such as COVID-19. This research seeks to contribute knowledge necessary to develop resources to support RPNs, so that they are less vulnerable as the workforce in this sector, in the event of a future pandemic or health crisis.

| Aim
This study aimed to understand how RPNs working in LTC homes in Ontario may have built and sustained personal and professional resilience during the COVID-19 global pandemic.

| Design
Constructivist grounded theory methodology (Charmaz, 2006) was used in this study to interpret the process of how RPNs maintain resilience during a crisis. Consistent with a constructivist lens, the knowledge generated in this research was shaped through an interactive dialogue between the researcher(s) and the research participants and the actions and processes are specific to context and experiences (Charmaz, 2000(Charmaz, , 2006. The findings of this study could, therefore, have analytical generalizability; that is, the results could lead to conceptual insights that provide new ways of considering issues in other settings (Charmaz, 2006).
Constructivist grounded theory is particularly appropriate to use when a study seeks to understand and conceptually map out a process. Such a process can be defined as 'unfolding temporal sequences that may have identifiable markers with clear beginnings and endings and benchmarks in between. The temporal sequences are linked in a process and lead to change' (Charmaz, 2006, p. 10).
This study explored the process of building and maintaining resilience amongst RPNs working in LTC during COVID-19. Inductive guidelines for data collection and analysis were employed to build a theoretical framework that would help interpret the data gathered (Charmaz, 2000). Methods of participant recruitment and selection, data collection and analysis are detailed below. The Consolidated Criteria for Reporting Qualitative Studies (COREQ; Tong et al., 2007) was used throughout the study design, data collection and analysis and in the writing of this manuscript.

| Sample of participants
RPNs working, or who had worked, in LTC homes in Ontario since January 2020 during the COVID-19 pandemic were eligible; nursing students, other categories of nurses (e.g. Registered Nurses [RNs]), or other healthcare professionals or staff were not. Eligible RPNs were invited to complete an online survey that aimed to describe the personal and professional resilience of RPNs working in LTC during the COVID-19 pandemic. Invitations to anonymously participate in the online survey were sent to registered RPNs by the WeRPN.
Results of the survey are reported elsewhere by this study's authors.
A letter explaining the purpose of the interview was provided at the end of the survey, and potential participants were invited to provide their contact information if they were willing to be interviewed by a research team member. Participants provided oral consent at the beginning of the interview, prior to the audio recording. All participant's data were deidentified and participants were able to withdraw consent for participation at any time. We used maximum variation and purposive sampling (Patton, 2002) to gain a broad representative sample of participants (e.g. age, gender, infection rate, geographic location, years employed as an RPN in LTC). Charmaz supports the notion of 'sampling adequacy' and redundancy in categories whereby sampling continues until no new knowledge is constructed or interpreted from the data collected.

| Data collection
The series of one-on-one, in-depth, semi-structured interviews

| Ethical considerations
This study was approved by Western University's Institutional Review Board (Study ID #118628). The RPNs who gave their consent to participate in the study were informed that they could withdraw from the study at any time or decline to respond to any question they preferred not to answer. Confidentiality was maintained by removing all identifying features of participants from the interview transcripts. All data was stored in a secure institutional one drive that was only accessible to study investigators. As per University of Western Ontario guidelines, data will be stored for a period of 7 years prior to being deleted. For the purposes of this manuscript, numbers have been used to identify participants instead of names.

| Data analysis
All interviews were transcribed verbatim. The process began by reading through interview transcripts several times and becoming familiar with the data to comprehend its essential features. The reflexive notes and transcribed interviews were analysed using the constructivist grounded theory approach outlined by Charmaz (2006).
Strategies included a two-step data coding process, comparative methods, reflective note writing to build conceptual analyses and the integration of a theoretical framework (Charmaz, 2000). Data were analysed throughout data collection using a social constructionist grounded theory approach to address the 'how' and 'why' questions underlying RPN stories of resilience.
Data were coded in a line-by-line fashion by two authors using NVIVO Version 2 (2006; QSR International Pty Ltd), a qualitative research software package. This software was used as an organizational, not analytical, tool. The analysis then progressed from lineby-line to focused coding, allowing codes to be brought together across observations and participants to create units of meaning (i.e. categories; Charmaz, 2004). A constant comparative method of analysis was used, comparing data generated in research participants' interviews, between participants, comparing experiences with other experiences and comparing the data generated by interviews in each category and between categories in conjunction with the interviewer's reflective notes (Charmaz, 2006). Analysis of de-identified transcribed interviews was ongoing as interviews were completed. Minor wording revisions were vetted by members of the research team to improve the clarity of the questions. This multistage coding and developing of categories resulted in the creation of a conceptual model of the process of how RPNs' personal and professional resiliency is either fueled or drained during a crisis such as COVID-19. Emerging ideas, concepts and the theoretical model were continually discussed with members of the research team to facilitate researcher reflexivity and enhance theoretical sensitivity.
Transcripts were not returned to participants for comment.

| Rigour
Quality criteria proposed by Charmaz (2006Charmaz ( , 2014, originality, resonance and usefulness, were observed. Conceptualizing the resilience of nurses as a product of individual and professional factors may be viewed as offering a fresh way (originality; Charmaz 2017) to consider the recognized problem of 'burnout' in the nursing workforce. Resonance demonstrates that the researchers have constructed concepts that not only represent their research participants' experience but also provide insight to others. Authentic citations were used to illuminate the constructed concepts to represent the research participants' experience (resonance; Charmaz 2017).
The study findings presented to the WeRPN Board of Directors, which includes RPNs, were confirmed to be applicable to their own experiences, and what members had relayed to the professional association. Findings of the study were collated into a Consultation Workbook in response to a call for reform of the Health Standards Organization National Long-Term Care Services Standard and contributed to a Report (HSO, 2022) with the aim to inform policy and practice applications (usefulness; Charmaz 2017). Transcripts were not returned to participants for comment and/or correction.

| FINDING S
The participant sample (n = 40) included 38 women (95%) and 2 men (0.05%), representing recruitment from 15 private (37.5%) and 25 public (62.5%) LTC homes in Ontario across all Ontario Local Health Integration Networks (LHINs) and four of the five Ontario Health Transitional Regions (see Table 1). There was no attrition. The average duration of an interview was 41.41 min (SD = 9.23 min, minimum time = 18.29 min, maximum time = 54.36 min). Participants' ages were not recorded to maintain anonymity. A total of 31 participants (77.5%) reported that their LTC home had been in a COVID-19 outbreak at some point since the pandemic began, whilst 9 participants (22.5%) reported that their workplace had never been declared to be in an outbreak.
Experiences storied by RPNs from working in LTC during the COVID-19 pandemic highlighted how RPNs described resilience (i.e. their capacity to adapt in the face of challenge). After 40 interviews, data saturation suggested that four themes had emerged: 'Dynamic Role of the Nurse', 'Preserving Self', 'Banding Together' and 'Sense of Leadership Support' (see Figure 1). These themes were regarded by RPN participants in distinct ways, either as a fuel or drain on their individual resilience. The process of maintaining individual resilience by RPNs was, at its essence, 'Emblazoned by Professional Identity' and fundamentally central to how they viewed themselves as nurses (i.e. the process of maintaining individual resilience by RPNs was governed by their professional identity as a nurse). This process is conceptualized as continually recurring whenever resilience was required from RPNs working in LTC and represents a process occurring in and over periods of time when RPNs were required to call on their capacity to adapt to challenge(s).

| Dynamic Role of the Nurse: 'Responsibility to keep going' vs. 'Thinking of quitting'
In the first theme, 'Dynamic Role of the Nurse', RPNs talked about their function as a nurse, coupled with either a sense of responsibility to 'keep going' [T27; T34; T68] and push through 'no matter what' [T68]; or thoughts about quitting because of a perceived lack of support and burnout. Importantly, several participants underscored their sense of responsibility to the residents and upholding a high standard of nursing care. This inherent desire to serve as a sense of support to the residents in LTC over the difficult first year of the pandemic was further stressed as family and/or care partners were prohibited from entering LTC homes. The way RPNs perceived their role as a nurse was foundational to their professional identity and fueled their responsibility to keep going:

| Preserving Self: 'It's about compartmentalizing things' vs. 'You get consumed by [work]'
In the second theme, 'Preserving Self', RPNs spoke about the need to compartmentalize their work from other aspects of their life, rather than being entirely consumed by it. When the process of 'Preserving

| Banding Together: 'We're all in it together' vs. 'Started turning on each other'
The  Being a member of the team, 'banding together', was described to be a positive factor in overcoming obstacles associated with the pandemic.
Sharing a common struggle brought some RPNs closer together. Some talked about how their families or friends could not understand their experience inside the LTC home, but their team of colleagues 'got it' and this validated their experiences, fueling their resilience to cope and adapt to the pandemic.

| Sense of leadership support: 'It's all on you' vs. 'Saw [management] more than ever'
The final theme, 'Sense of Leadership Support', was also regarded by RPN participants in distinct ways, either as a fuel or drain on their individual resilience. RPNs voiced that they felt either aban-  Our study affirmed that a sense of leadership support is an important factor in maintaining individual resilience and that participants required additional mental health supports: something that has been considered in this workforce long before COVID-19 (Woodhead, Northrop & Edelstein, 2016). Previous research demonstrates that job demands (e.g. greater occupational stress) are associated with more emotional exhaustion, more depersonalization and less personal accomplishment (Woodhead, Northrop & Edelstein, 2016).
Although the current study did not directly measure mental health, findings from Japan suggest that 10% of healthcare workers developed moderate-to-severe anxiety disorders, and roughly 28% developed depression during COVID-19 (Awano et al., 2020). Problems with anxiety and fear of infection and death, isolation and unreasonable treatment and motivation and escape from work were higher in the group who experienced depression relative to the group who did not. This is also demonstrated by research studying front-line nursing home staff experiences during COVID-19 in Ontario (White et al., 2021). Our participants reported a need to preserve their sense of self, commonly through the strategy of compartmental-  (Havaei et al., 2021). Our participants perceived their leaders as providing support when they stayed at work and missed their holidays.
This might suggest that to fuel RPN's resilience, the perception of leaders going above and beyond their regular call of duty may be advantageous.
To address the systemic problems of staffing shortages and burnout in LTC that have been amplified by COVID-19, we must consider the change to systems, policies and practices in the short-and longterm. Healthcare or organizational resilience is defined as the capacity to adapt to challenges and changes at different systems levels, to maintain high-quality care. 'Capacity' refers to a 'set of capacities' (e.g. the materials and resources that underpin resilience) at individual, team and system levels (Wiig et al., 2020, p. 6). 'Adapt' refers to a process of how nurses 'continue to operate and deliver services despite stress, disruptions, unforeseen events, and insufficient resources and competence' (Wiig et al., 2020). Fused together, capacity and adaptation signal the need for increased resources that might bolster resil-  (Dawson et al., 2021). The focus should be on workforce development, funding reform and the creation of a sustained agefriendly health system, inclusive of a resilient healthcare workforce.
For the profession of RPNs, leadership support needs to increase, and opportunities need to be provided for RPNs to work as a team. Currently, in the RPN profession, there is a juxtaposition between the nursing role and the professional obligations of the job.
As a result of poor work-life balance, being consumed by work, and being exposed to trauma, RPNs may require greater access to sick leave provisions and mental health resources. Additionally, findings from this study suggest a needed emphasis on the immediacy of support at the moment. Additionally, long-term support is needed to address vicarious trauma and secondary traumatic stress in healthcare professionals (Guitar & Molinaro, 2017).

| Limitations
To our knowledge, this is the first study describing the process of how RPNs maintain individual resilience whilst working in LTC homes during the COVID-19 pandemic. This is a qualitative constructed grounded theory study; therefore, the generalizability of these findings is limited. There are also some methodological limitations associated with the use of the Zoom platform for data collection. Technological competence may be challenged by audio and visual impairments, or other physical limitations which may make it difficult to use the computer, tablet, or phone (Howlett, 2021). Video conferencing can be unreliable when the internet is unstable, resulting in problems (audio cut-offs) that would not happen in person. Howlett (2021) suggests that online research is now an equally valid approach to research as in-person interactions and noted that her participants were noticeably more comfortable engaging in research online than in in-person interactions.

| CON CLUS ION
Resilience in RPN study participants working in LTC during the pandemic was described as largely individual resilience. Study findings informed two distinct perspectives on nurses' resilience in LTC, one where nurses were able to maintain resilience (i.e. sustaining) and another where they were not (i.e. fraying). Sustaining and fraying resilience presented as bimodal processes; four themes were identi-

ACK N OWLED G EM ENT
We acknowledge that this research would not be possible without our partnership with the Registered Practical Nurses Association of Ontario (WeRPN).

This research was funded by a Social Sciences and Humanities
Partnership Engagement Grant in partnership with the Registered Practical Nurses Association of Ontario (WeRPN).

CO N FLI C T O F I NTE R E S T
No conflict of interest has been declared by the author(s).

PE E R R E V I E W
The peer review history for this article is available at https://publo ns.com/publo n/10.1111/jan.15453.

DATA AVA I L A B I L I T Y S TAT E M E N T
The authors does wish to share the Research data.